Contraception after heart transplantation

It was observed that fertility and menstrual function in heart-transplanted women, impaired before the operation, become normal with a new heart. The restoration of reproductive function is also confirmed by many cases of pregnancy in heart-transplant recipients, reported in the literature. Twenty-four cases were published worldwide up to 1997, out of which eighteen had a positive result. Also a case personally treated was successful. The outcome of a pregnancy after heart transplantation is, then, generally positive. Nevertheless, such a pregnancy involves important maternal and fetal risks. Thus, the gynecologist has to provide correct information about both such risks and the most suitable contraceptive methods, for these patients. Oral contraceptives are very effective and, in the new low-dose formulations, free from serious adverse effects. No adverse effects have been observed in our patient, who represents the only case, reported in the literature, in which an estroprogestinic contraception was utilized before a pregnancy. In conclusion, during an oral contraception or after a tubal sterilization, pregnancy is really unlikely to occur. Thus, when the couple either has completed the familial nucleus or does not desire offspring, a doubt is at least justified as to whether these safer methods of contraception are advisable in such women.     

Ventricular remodeling of the native heart after heterotopic heart transplantation.

Although ventricular remodeling after long-term unloading of the heart has been reported in patients after the use of medical therapy or left ventricular assist devices, it has rarely been reported in patients after heterotopic heart transplantation. Here, we describe a case of ventricular remodeling of the native heart after heterotopic heart transplantation. A 61-year-old man with end-stage dilated cardiomyopathy underwent heterotopic heart transplantation because of high pulmonary vascular resistance and a small donor heart. After the operation, echocardiography showed ventricular remodeling of the native heart, with decreased size and improved contractility of the left ventricle. Six months after the transplantation, acute graft failure of the donor heart occurred. However, the patient remained in good condition with the support of the improved native heart.     

Amplatzer septal occluder-induced transient complete atrioventricular block.

Percutaneous transcatheter atrial septal defect (ASD) closure is a widely used technique that has replaced open-heart surgical closure in many centers. The most common implant is the Amplatzer septal occluder which seems to be a highly effective and safe device. However, there are reports of complications associated with its implantation. We report a 9-year-old boy who presented with complete atrioventricular block after undergoing percutaneous closure of a large secundum ASD with an Amplatzer septal occluder. We treated the patient with oral prednisolone. The patients atrioventricular conduction improved to second-degree Mobitz type 1 block on post-procedure day 24 and first-degree block on day 35. We conclude that patients with Amplatzer septal occluder-induced complete atrioventricular block generally have a good outcome, although it may take several weeks for improvement.     

Antenatal diagnosis of atrioventricular block. A case report

The authors report the case of a congenital atrio-ventricular block (AVB) diagnosed after 32 weeks of amenorrhea in a woman, suffering from AVB, fitted with a pacemaker and who had already given birth to two children suffering from congenital AVB. The authors recall the physiopathology and antenatal diagnostic criteria of AVB and how it should be managed.     

Fetus with heart failure due to congenital atrioventricular block treated by maternally administered ritodrine

BACKGROUND: The efficacy of maternal administration of ritodrine in cases of congenital atrioventricular block (CAVB), especially with fetal heart failure, is not yet determined. CASE: At 21 2/7 weeks of gestation, isolated CAVB with a ventricular/atrial rate of 55-70/130-140 bpm was found in a fetus from a 30-year-old Japanese nulliparous woman with anti-SSA antibody. Cardiothoracic area ratio (CTAR) was 40% and no fetal hydrops was observed. At 30 2/7 weeks, the ventricular rate decreased to 49 bpm with an atrial rate of 125 bpm. CTAR increased to 53.8% and ascites appeared. Maternal continuous ritodrine infusion was started with rapid improvement of fetal cardiac function; increment in the ventricular rate to 57 bpm and atrial rate to 137 bpm, with a decrement in CTAR to 44.6%. Ascites also gradually decreased and by the fourth day, it had completely disappeared with CTAR of 40.2%. On the 12th day after ritodrine treatment (32 1/7), amniotic fluid volume decreased and fetal weight gain stopped, which led us to assume a worsening intrauterine environment, and cesarean section was performed. A 1,178 g male infant was born with a 5-min Apgar score of 8. Continuous isoproterenol infusion was started, increasing the ventricular rate from 71 to 80 bpm. Pacemaker implantation is under consideration to treat this infant. CONCLUSION: Maternal administration of ritodrine not only increased the fetal heart rate but also ameliorated the signs of fetal heart failure, and thus is considered one treatment of choice in CAVB.     

心肌炎所致小儿完全性房室传导阻滞17例临床分析

目的分析感染性心肌炎所致小儿完全性房室传导阻滞(CAVB)的临床特点及治疗，以提高对该病的认识。 方法对1984-08—2005-03上海市交通大学附属儿童医院收治的感染性心肌炎所致CAVB17例进行回顾性分析。 结果17例CAVB患儿出现阿斯综合征者8例，心功能不全者5例。17例胸片检查心影增大13例。13例心脏超声检查示均有左心室增大。心电图示平均心室率为(528±104)/min。急重症心肌炎6例，均予甲基泼尼松龙静脉冲击和营养心肌治疗，3例安置临时起搏器进行治疗;其余患儿都以改善传导、增快心室率药物治疗。治愈6例，好转5例，仍为CAVB 5例，死亡1例。 结论急重症心肌炎发生CAVB可以是致命的，如果能早期诊断、及时应用大剂量肾上腺皮质激素及给予急诊临时起搏器处理，将会取得较好的预后。在随访心肌炎所致房室传导阻滞患儿时，如并有束支传导阻滞者、QRS波增宽、结性逸搏时要高度警惕其可能进展为CAVB。     

Resumption of sinus rhythm from fetal complete atrioventricular block after maternally administered ritodrine

Reports have indicated that maternal administration of ritodrine increased the ventricular rate and thus ameliorated signs of heart failure in a fetus with complete atrioventricular block (CAVB). A fetus from a mother without the anti-SS-A/SS-B antibody had CAVB, with atrial rate 148–154 bpm and ventricular rate 53–57 bpm. After maternal administration of ritodrine, the ventricular rate increased to 60–65 bpm, and then sinus rhythm resumed. Ritodrine may not only increase the ventricular rate but also induce sinus rhythm in a fetus with CAVB.     

A management strategy for fetal immune-mediated atrioventricular block

Introduction.?The purpose of this study is to describe an in utero management strategy for fetuses with immune-mediated 2° or 3° atrioventricular (AV) block.

Methods and results.?The management strategy as applied to 29 fetuses consisted of three parts. First, using fetal echocardiography and obstetrical ultrasound, we assessed fetal heart rate (FHR), heart failure, growth and a modified biophysical profile score (BPS) assessing fetal movement, breathing and tone. Second, we treated all fetuses with transplacental dexamethasone, adding terbutaline if the FHR was?<56 bpm. Digoxin and/or intravenous immune globulin (IVIG) was added for progressive fetal heart failure. Third, we delivered fetuses by cesarean section for specific indications that included abnormal BPS, maternal/fetal conditions, progression of heart failure, or term pregnancy. We assessed perinatal survival, predictors of delivery and maternal/fetal complications in 29 fetuses with 3° (n?=?23) or 2° (n?=?6) AV block. There were no fetal deaths. In utero therapy included dexamethasone (n?=?29), terbutaline (n?=?13), digoxin (n?=?3) and/or IVIG (n?=?1). Delivery indications included term gestation (66%), fetal/maternal condition (14%), low BPS (10%) and progression of fetal heart failure (10%). An abnormal BPS correlated with urgent delivery.

Conclusion.?These results suggest that applying this specific management strategy that begins in utero can improve perinatal outcome of immune-mediated AV block.     

Renal dysfunction after heart transplantation: incidence, prognosis and risk factors.

BACKGROUND AND PURPOSE: Despite more than 20 years of experience in heart transplantation, the risk factors for development of chronic renal insufficiency in recipients are not well established. This study assessed the incidence, prognosis and risk factors for renal dysfunction after heart transplantation. METHODS: We conducted a retrospective analysis of all adult patients (n = 132) who survived for more than 1 year after heart transplantation at our institutions from March 1992 through November 2002. Renal dysfunction was defined as serum creatinine of > or = 2.0 mg/dL. The incidence and prognosis of renal dysfunction after heart transplantation was estimated by the Kaplan-Meier method and compared by log rank test. Risk factors for renal dysfunction at 1 year after transplantation were evaluated using a logistic regression model. RESULTS: Renal dysfunction was present in 9 patients (7%) before heart transplantation. The cumulative incidence of renal dysfunction after heart transplantation was 23.0 +/- 3.8%, 36.1 +/- 4.3%, 53.9 +/- 4.9%, and 57.3 +/- 5.8% at 6 months, 1 year, 5 years and 10 years, respectively, after transplantation. The actuarial survival rate in patients without renal dysfunction at 1 year after transplantation was better than for patients with renal dysfunction at 1 year after transplantation (p = 0.046 by log-rank test). Independent risk factors for renal dysfunction at 1 year after transplantation were age at transplantation (odds ratio, 1.07; p = 0.02), pretransplant serum blood urea nitrogen (odds ratio, 1.07; p = 0.048), and serum creatinine at 6 months after transplantation (odds ratio, 17.0; p < 0.001). CONCLUSIONS: There was a high incidence of renal dysfunction after heart transplantation. Patients with renal dysfunction had poor long-term prognosis. Serum creatinine at 6 months after transplantation was the most significant major risk factor, followed by age at transplantation and pretransplant blood urea nitrogen.     

Combined echocardiographic and Doppler assessment of fetal congenital atrioventricular block

Summary. Fetal heart rate monitoring was combined with fetal echocardiography for examination of atrial reactivity during labour in five fetuses with second or third degree heart block. Alterations in vagal tone accompanying uterine contraction influence atrial rate, even when the ventricle is not under atrial'control'. Fetal echocardiography enabled diagnosis of the underlying basis of the arrhythmia and located the optimal position for recording atrial activity with an external heart rate monitor. External and internal monitoring of atrial activity demonstrated reactivity during labour. Two patients were delivered vaginally after monitoring throughout labour. One mother preferred elective caesarean delivery. Caesarean section was required in another for cephalopelvic disproportion and in the remaining woman for late decelerations. These monitoring techniques provide an assessment of fetal well-being in the presence of fetal bradycardia due to variable degrees of heart block.     

Autoimmune-mediated congenital heart block

Autoimmune-mediated congenital heart block (CHB) is a severe manifestation of neonatal lupus in which conduction tissues of the fetal heart are damaged. This occurs due to passive transference of maternal anti-SSA/Ro and anti-SSB/La autoantibodies and subsequent inflammation and fibrosis of the atrioventricular (AV) node. Notably, the disease manifests after the fetal heart has structurally developed, ruling out other anatomical abnormalities that could otherwise contribute to the block of conduction. Complete AV block is irreversible and the most common manifestation of CHB, although other cardiac complications such as endocardial fibroelastosis (EFE), dilated cardiomyopathy, and valvular insufficiency have been observed. In this review, we detail the classification, prevalence, pathogenesis, and clinical management recommendations for autoimmune CHB.     

Combined echocardiographic and Doppler assessment of fetal congenital atrioventricular block

Fetal heart rate monitoring was combined with fetal echocardiography for examination of atrial reactivity during labour in five fetuses with second or third degree heart block. Alterations in vagal tone accompanying uterine contraction influence atrial rate, even when the ventricle is not under atrial 'control'. Fetal echocardiography enabled diagnosis of the underlying basis of the arrhythmia and located the optimal position for recording atrial activity with an external heart rate monitor. External and internal monitoring of atrial activity demonstrated reactivity during labour. Two patients were delivered vaginally after monitoring throughout labour. One mother preferred elective caesarean delivery. Caesarean section was required in another for cephalopelvic disproportion and in the remaining woman for late decelerations. These monitoring techniques provide an assessment of fetal well-being in the presence of fetal bradycardia due to variable degrees of heart block.     

Optimal ventricular pacing rate in fetal lambs with complete atrioventricular block

OBJECTIVE: This study was undertaken to determine the optimum ventricular pacing rate at which the optimal cardiac function can be attained in fetal lambs with complete atrioventricular block. STUDY DESIGN: Complete atrioventricular block was created by cryosurgery in 12 fetal lambs, and the ventricle was paced randomly at rates of 60, 90, 120, 150, 180, 210, 240, and 270 beats/min. The aortic pressure, central venous pressure, and right ventricular cardiac output were measured before cryosurgery and during ventricular pacing. RESULTS: Complete atrioventricular block was created in 9 of 12 fetal lambs. Systolic aortic pressure significantly decreased at pacing rates of 60, 90 and 240 beats/min (P <.01), and central venous pressure was increased significantly at a pacing rate of 60 beats/min (P <.01) compared with the control. Right ventricular cardiac output significantly decreased at pacing rates of 60, 90, 120, 180, 210, 240, and 270 beats/min (P <.01), although no significant difference was found at the pacing rate of 150 beats/min compared with control. CONCLUSION: Ventricular pacing at a rate of 150 beats/min gave the highest aortic pressure, the lowest central venous pressure, and the highest right ventricular cardiac output in fetal lambs with complete atrioventricular block.